All citations for Autumn Lake Healthcare at Birch Manor

State inspectors check nursing homes that take Medicare or Medicaid against federal rules, usually about once a year, and also look into complaints. Each rule a home did not meet is a citation.

Back to Autumn Lake Healthcare at Birch Manor

Last standard health inspection on record

June 11, 2025

Showing 1 to 25 of 85 citations

  1. No harm, with potential for more than minimal harm

    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

    Widespread (many residents). CMS level F.

    Health citation F-0657, Resident Assessment and Care Planning Deficiencies. Inspection of June 11, 2025. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (July 15, 2025).

  2. No harm, with potential for more than minimal harm

    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

    Widespread (many residents). CMS level F.

    Health citation F-0655, Resident Assessment and Care Planning Deficiencies. Inspection of August 3, 2018. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 8, 2018).

  3. No harm, with potential for more than minimal harm

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

    Widespread (many residents). CMS level F.

    Health citation F-0656, Resident Assessment and Care Planning Deficiencies. Inspection of August 3, 2018. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 8, 2018).

  4. No harm, with potential for more than minimal harm

    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

    Widespread (many residents). CMS level F.

    Health citation F-0657, Resident Assessment and Care Planning Deficiencies. Inspection of August 3, 2018. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 8, 2018).

  5. No harm, with potential for more than minimal harm

    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

    Widespread (many residents). CMS level F.

    Health citation F-0842, Resident Assessment and Care Planning Deficiencies. Inspection of August 3, 2018. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 8, 2018).

  6. No harm, with potential for more than minimal harm

    Keep all essential equipment working safely.

    Widespread (many residents). CMS level F.

    Health citation F-0908, Environmental Deficiencies. Inspection of August 3, 2018. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 8, 2018).

  7. No harm, with potential for more than minimal harm

    Honor the resident's right to organize and participate in resident/family groups in the facility.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0565, Resident Rights Deficiencies. Inspection of June 11, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 15, 2025).

  8. No harm, with potential for more than minimal harm

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0656, Resident Assessment and Care Planning Deficiencies. Inspection of June 11, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 15, 2025).

  9. No harm, with potential for more than minimal harm

    Provide activities to meet all resident's needs.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0679, Quality of Life and Care Deficiencies. Inspection of June 11, 2025. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (July 15, 2025).

  10. No harm, with potential for more than minimal harm

    Provide and implement an infection prevention and control program.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0880, Infection Control Deficiencies. Inspection of June 11, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 15, 2025).

  11. No harm, with potential for more than minimal harm

    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0584, Resident Rights Deficiencies. Inspection of November 4, 2024. Found during a complaint inspection.

    The home gave a date the problem would be corrected (December 6, 2024).

  12. No harm, with potential for more than minimal harm

    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

    Pattern (more than a few residents). CMS level E.

    Health citation F-0655, Resident Assessment and Care Planning Deficiencies. Inspection of June 9, 2021. Found during a standard inspection.

    The home gave a date the problem would be corrected (August 6, 2021).

  13. No harm, with potential for more than minimal harm

    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0657, Resident Assessment and Care Planning Deficiencies. Inspection of June 9, 2021. Found during a standard inspection.

    The home gave a date the problem would be corrected (August 6, 2021).

  14. No harm, with potential for more than minimal harm

    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0842, Resident Assessment and Care Planning Deficiencies. Inspection of June 9, 2021. Found during a standard inspection.

    The home gave a date the problem would be corrected (August 6, 2021).

  15. No harm, with potential for more than minimal harm

    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0580, Resident Rights Deficiencies. Inspection of August 3, 2018. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 8, 2018).

  16. No harm, with potential for more than minimal harm

    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0584, Resident Rights Deficiencies. Inspection of August 3, 2018. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 8, 2018).

  17. No harm, with potential for more than minimal harm

    Ensure each resident receives an accurate assessment.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0641, Resident Assessment and Care Planning Deficiencies. Inspection of August 3, 2018. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 8, 2018).

  18. No harm, with potential for more than minimal harm

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0684, Quality of Life and Care Deficiencies. Inspection of August 3, 2018. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 8, 2018).

  19. No harm, with potential for more than minimal harm

    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0758, Pharmacy Service Deficiencies. Inspection of August 3, 2018. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 8, 2018).

  20. No harm, with potential for more than minimal harm

    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0761, Pharmacy Service Deficiencies. Inspection of August 3, 2018. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 8, 2018).

  21. No harm, with potential for more than minimal harm

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0812, Nutrition and Dietary Deficiencies. Inspection of August 3, 2018. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 8, 2018).

  22. No harm, with potential for more than minimal harm

    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

    Pattern (more than a few residents). CMS level E.

    Health citation F-0868, Administration Deficiencies. Inspection of August 3, 2018. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 8, 2018).

  23. No harm, with potential for more than minimal harm

    Implement a program that monitors antibiotic use.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0881, Infection Control Deficiencies. Inspection of August 3, 2018. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 8, 2018).

  24. No harm, with potential for more than minimal harm

    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0925, Environmental Deficiencies. Inspection of November 20, 2025. Found during a complaint inspection.

    The home gave a date the problem would be corrected (January 5, 2026).

  25. No harm, with potential for more than minimal harm

    Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0568, Resident Rights Deficiencies. Inspection of June 11, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 15, 2025).

Source: CMS Provider Information, Fire Safety Deficiencies, Health Deficiencies, Citation Code Look-up, data as of September 30, 2026. Inspection results describe the home at the time of each inspection.